Rewriting the script on oral therapeutics

When it comes to eye care, optometrists have long been the first line of defence against a range of ocular issues. But, while they play a pivotal role in diagnosing and managing a multitude of eye conditions, their prescribing authority is limited to topical treatments like eye drops and ointments, which are oftentimes inadequate.

This is a predicament that David Foresto, optometrist and practice owner in Brisbane, is all too familiar with. In his contact lens practice, David regularly fits custom-made contact lenses, most notably for patients with keratoconus, corneal grafts and babies with congenital cataract. Over his 20-year career, he says he can recall hundreds of cases where patients have been misdiagnosed or late-diagnosed, and where the timing for effective treatment was extremely narrow. ‘In some of the cases I’ve seen, if the practitioner had initiated tablets within the first couple of days, they would’ve most likely gotten on top of it before it worsened,’ he said.

David has a well-known reputation for advanced contact lens care, especially with the fitting of scleral contact lenses. He was on the Optometry Queensland Northern Territory board for 10 years and served as its President for three years. Amid his busy career, he also dedicates time as a guest lecturer at Queensland University of Technology.

Q: What are your views and feelings on optometrists and oral therapeutics?

David: For me, it’s not about feeling frustrated at not being able to prescribe oral medications for ocular conditions. It’s that we aren’t provided the tools to treat things in the most effective and evidence-based way. I don’t actually care whether the best treatment is an eye drop or a tablet, I just want my patients to have the best treatment. I don’t have a personal ambition to be a medical doctor. I’m not trying to be an ophthalmologist or treat systemic diseases. I have great respect for each of those professions. I’m just trying to treat ocular conditions in the most effective way, which is exactly what the public expects optometrists to do.

It’s a common situation: I’ll be looking into someone’s eye through a slit lamp, and I’ll know immediately what the best treatment is, but I’m not allowed to prescribe it. The most common of these situations is viral keratitis. I then have to decide between either providing the patient with a less effective treatment or referring them to another practitioner for more effective treatment, or even worse, calling a GP and asking them to do an emergency prescription over the phone – which is an awful position to put another health practitioner in. This whole process causes inconvenience and costs to the patient and the health system and it creates ambiguity in which practitioner is accepting the liability for this diagnosis and treatment. It doesn’t make sense to me; it’s bad for the patient, it’s bad for the health system, it’s bad for everyone.

Q: What are your thoughts on optometrists overseas having access to oral therapeutics? 

David: There’s no doubt that Australians are getting left behind globally. The changes in New Zealand show that they see a need for this, and the US has always been ahead of us. Optometrists in the US have had a long and safe history of prescribing oral therapeutics for ocular use. I’ve always regarded Australia as having the second highest standard of optometry in the world after the US, and, I think, the highest standard of contact lens care in the world, but unfortunately without oral therapeutics for ocular use we are definitely slipping down the list. But it’s not about us, it’s about public health. Australia’s decisions about scope of practice and what can be prescribed should be based only on a rational assessment of risk versus benefit to the public and the best therapies shouldn’t be arbitrarily ruled out because of their route of administration.

Q: Can you share a situation where your patient would have benefited from an oral medication?

David: Because of my work fitting custom contact lenses to people with corneal transplants, I’ve met a lot of patients who’ve had serious corneal damage from viral keratitis – usually herpetic. Some of those patients with herpetic keratitis end up with corneal transplants, some of them don’t, but many of them have some level of neuropathic pain – pain that can continue for the duration of their life. Rarely can we fully restore their vision and their ocular comfort to what it was before the infection if it has been allowed to progress to a severe state. These are the cases that get out of hand; these patients have such severe damage that they end up with corneal transplants or need custom contacts. They would have had less likelihood of that happening if somebody could have jumped on it at the very first opportunity and provided the most effective treatment, which in those cases are tablets. Tablets which incidentally are allowed to be prescribed over the counter by pharmacists for other conditions.

We’ve been told in cases like these that we have to provide patients with eye drops or eye ointment, but we know tablets are more effective. Also, the ointment has a history of being out of supply. So, while this is the case, there’s going to be more patients who end up with damaging lifelong problems after herpetic keratitis because we’re not allowed to initiate treatment early. In situations like these, the gatekeeping of oral antivirals is just harming patients.

It really does matter because people walk into us, the optometrist, on day one, and they might have a little bit of an irritated eye or they’re a bit glare sensitive – we can see it with the microscope in the earliest stages, diagnose it, knock it on the head, and then that’s it. The infection might come back in the future, but they know what to do and where to go. In the current arrangement, people are attending optometry practices and the optometrist is having to either initiate a second tier of treatment such as ointment or get on the phone to the GP for a prescription. Yet, we’re the ones with the microscope making the diagnosis?

It’s senseless, because if you look at the side effect profile of some tablets compared to the side effect profile of some topical eye drops that we’re allowed to prescribe, the tablet is very low risk in comparison.

Q: How do you see optometry access to oral therapeutics benefitting the broader health system?

David: There may be a natural apprehension from other medical doctors to be resistant to optometrists prescribing oral medications, and that might be reasonable if we were looking to treat systemic conditions, but we’re not. We’re only seeking to treat ocular conditions – we’re not doing anything that’s not ocular and we’re not asking for anything that’s not ocular. Tablets do not necessarily have more systemic side effects than some eyedrops.

We also need to be prepared for the future. If we’re not already able to prescribe low risk, safe medications, then we’re also not setting the Australian population up for very good eye care. Countries like New Zealand and the UK don’t have the geographical access issues that we have. Australia is far more spread out than nearly any other country on earth, so access to treatment is really important.

Q: What other benefits do you see in optometrists having access to oral prescribing?

David: I could tell you about hundreds of cases of patients who have been misdiagnosed with a corneal abrasion or conjunctivitis when, in actual fact, they had a viral keratitis. The first day or two when someone has a viral corneal infection, there is very little to see if you don’t have a slit lamp. You’re not going to see the early signs of keratitis unless you’re lucky. Whereas us with a slit lamp will be able to see it – we might be able to see the white cells in the cornea or a single dendrite and tell this is a very early viral keratitis. Timing makes all the difference. If you’re initiating the tablets within the first couple of days, you’re most likely going to get on top of it before it causes scarring or spreads.

Q: How do you see the role of optometry expanding with this change?

David: The global trend is that optometrists are becoming increasingly utilised within eye clinics to manage eye care whilst ophthalmologists focus on surgery and other interventions. You can see this being embraced within private ophthalmology practices here already. Once there are therapeutics to treat presbyopia, the community need for optical dispensing will rapidly diminish. 

20 years ago, I was really chuffed that we were allowed to prescribe topical therapeutics. At the time, there was no way that I would have imagined 20 years later that we still wouldn’t have the ability to prescribe any oral therapeutics at all. I was just a new graduate at the time that it happened, so I was able to see just how much work and effort went into that and just how committed that generation of optometrists were to be able to expand our scope of practice to best care for patients.

I’m grateful to that generation and I’m a little disappointed that we’re still in the same position, and that we haven’t taken that next logical step to prescribing a limited range of oral therapeutics for ocular conditions. But hopefully that can change soon.